Despite skilled palliative care, some dying patients experience distressing
symptoms that cannot be adequately relieved. A patient with metastatic breast
cancer, receiving high doses of opioids administered to relieve pain, developed
myoclonus. After other approaches proved ineffective, palliative sedation
was an option of last resort. The doctrine of double effect, the traditional
justification for palliative sedation, permits physicians to provide high
doses of opioids and sedatives to relieve suffering, provided that the intention
is not to cause the patient’s death and that certain other conditions
are met. Such high doses are permissible even if the risk of hastening death
is foreseen. Because intention plays a key role in this doctrine, clinicians
must understand and document which actions are consistent with an intention
to relieve symptoms rather than to hasten death. The patient or family should
agree with plans for palliative sedation. The attending physician needs to
explain to them, as well as to the medical and nursing staff, the details
of care and the justification for palliative sedation. Because cases involving
palliative sedation are emotionally stressful, the patient, family, and health
care workers can all benefit from talking about the complex medical, ethical,
and emotional issues they raise.
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